Docstoc

Illinois Insurance Company

Document Sample
Illinois Insurance Company Powered By Docstoc
					http://insurance.illinois.gov                                                                                              Year
                                                     Illinois Department of Insurance
                                                     Farm Mutual Annual Statement

                                                                                                                           Insurance Company
                                            (Company Name)


                        (Mailing Address)                                                            (City, State & Zip Code)


Organized or Incorporated                                                                  Commenced Business



                        (Phone No.)                                (Fax No.)                         (Federal Employer's Identification No.)


E-mail Address:


                                                  Financial Statement as of December 31,


                                                                 Officers
                                              Name                                         Address                               Term Expires

President

Vice Pres.

Secretary

Treasurer




                                                                Directors

                   1.

                   2.

                   3.

                   4.

                   5.

                   6.

                   7.

                   8.

                   9.

                  10.

                  11.

                  12.

                  13.

                  14.

                  15.
IL446-0199 (Rev. 11/04)
                              Table of Contents

Assets:

Schedule A, pages 7 and 8                                                      Cash

Schedule B, page 9                                                            Bonds

Schedule C, pages 10 and 11                                  Stock and Mutual Funds

Schedule D, page 12                                                      Real Estate

Schedule E, page 13                                Realized Capital Gains and Losses

Schedule F, page 14                                               Investment Income

Underwriting:

Schedule G, page 15                               Net Unpaid Losses & Adjusting Fees

Schedule H, page 16                                              Unearned Premium

Schedule I, page 17                                                 Premium Earned

Schedule J, page 18                                                  Losses Incurred

Schedule K, page 19                                                    LAE Incurred

Schedule L, page 20                                        Net Commission Expense

Schedule M, page 20                                           Income Taxes Incurred

Schedule N, page 21                                     Other Underwriting Expenses
                                                                                   Year

                                                              Insurance Company

1 Amount of total ledger assets, p. 5 col. 1, line 18, December 31 of previous year            $0


                                                         Receipts of Ledger Assets

2 Premiums Received:
  a. Fire and other perils                                                    $0
  b. Wind                                                                     $0
3 Gross survey, membership, and policy fees                                   $0
4 Assumed reinsurance premiums received                                       $0
5    Total premiums and fees (lines 2 through 4)                                          $0
     Deduct:
6    Proportional or pro rata reinsurance
     a. Fire and other perils                                                 $0
     b. Wind                                                                  $0
7    Excess loss, catastrophe, and facultative reinsurance
     a. Fire and other perils                                                 $0
     b. Wind                                                                  $0
8    Returned on cancellations
     a. Fire and other perils                                                 $0
     b. Wind                                                                  $0
 9       Total deductions (lines 6 through 8)                                             $0
10   Net Premiums and fees (line 5 minus line 9)                                               $0
11   Interest received on bonds (p. 9, col.9)                                 $0
12   Interest received on bank deposits (p. 8, col.5)                         $0
13   Dividends received or reinvested (p.11, line 23)                         $0
14   Rents (p. 12, col. 9)                                                    $0
15   Borrowed money                                                           $0
16   Cash received from sale or redemption of ledger assets                   $0
17   Cash received from sale of non-ledger assets                             $0
18   Commission on ceded reinsurance                                          $0
19   Premiums collected on combination policies
     (p. 24, line 2 minus p. 24, line 3)                                      $0
20   Commissions on combination policies (p. 24, line 3)                      $0
21   Income taxes received (Sch. M, p. 20, line 1)                            $0
22   *Aggregate write-ins (itemize)                                           $0
23       Total other receipts (lines 11 thru 22)                                               $0
24       Total receipts (line 10 plus line 23)                                                 $0
25   Amount carried forward (line 1 plus line 24)                                              $0
 * List of write-ins on page 22




                                                                     -1-
                                                                                   Year

                                                                     Insurance Company

                                                          Disbursements of Ledger Assets

1    Amount brought forward (page 1, line 25)                                                  $0
2    Gross losses paid to policyholders                                       $0
3    Reinsurance losses paid (on assumed business)                            $0
4       Total losses paid (line 2 plus line 3)                                            $0
5    Salvage and subrogation (p.18, col. 3)                                   $0
6    Recovered from reinsurance (p 18, col. 4 plus
     p.19, col. 3)                                                            $0
7    Total loss reduction (line 5 plus line 6)                                            $0
8    Net losses paid (line 4 less line 7)                                                      $0
9    Adjusting expense (p. 19, col. 2)                                                    $0
10   Legal and auditing expense                                                           $0
11   Payments to agents including commissions and
     fees retained by agents                                                              $0
12   Salaries and expenses of directors, officers,
     and committees                                                                       $0
13   Salaries of office employees                                                         $0
14   Premium on officers' bonds                                                           $0
15   General office expense including rent                                                $0
16   Taxes and repairs on real estate                                                     $0
17   Insurance department licenses and fees                                               $0
18   Payroll taxes                                                                        $0
19   Advertising, printing, and stationery                                                $0
20   Telegraph, telephone, express, and postage                                           $0
21   National and state association dues                                                  $0
22   Fire department fees                                                                 $0
23   Agents' balances charged off                                                         $0
24   Borrowed money repaid                                                                $0
25   Interest on borrowed money                                                           $0
26   Book value of ledger asset sold or redeemed                                          $0
27   Purchase of non-ledger asset                                                         $0
28   Annual depreciation expense (p. 12, col. 7)                                          $0
29   Combination policy premiums remitted (p. 24, line 4a)                                $0
30   Combination policy commissions paid (p. 24, line 4b)                                 $0
31   Combination policy returns and cancellations (p. 24, line 4c)                        $0
32   Income taxes paid (Sch. M, p. 20, line 4)                                            $0
33   *Aggregate write-ins (itemize)                                                       $0
34   Total other disbursements (lines 9 through 33)                                            $0
35   Total disbursements (line 8 plus line 34)                                                 $0
36   Ledger assets (line 1 minus line 35) (p. 5, col.1, line 18)                               $0
     *List of write-ins on page 22.
                                                                        -2-
                                                                                             Year
                                                                Insurance Company


                                                                Admitted Assets


                                                                            (1)                           (2)
                                                                      Admitted Assets               Admitted Assets

                                                                       Current Year                   Prior Year

 1 Cash in company's office                                                             $0                         $0

 2 Cash on deposit in checking account (p. 7, col. 4)                                   $0                         $0

 3 Other cash deposits (p. 8, col.4)                                                    $0                         $0

 4 Bonds (at amortized cost) (p. 9, col. 6)                                             $0                         $0

 5 Mutual funds (at market value) (p. 10, col. 6, line 8)                               $0                         $0

 6 Preferred stock (at market value) (p. 10, col. 6, line 16)                           $0                         $0

 7 Common stock (at market value) (p.10, col. 6, line 24)                               $0                         $0

7a Total invested assets (line 1+2+3+4+5+6+7)                                           $0                         $0

 8 Real Estate (net of accumulated depreciation and
   encumbrances) (p. 12, col. 10)                                                       $0                         $0

 9 Agents' balances/uncollected premiums                                                $0                         $0

10 Invested income due and accrued                                                      $0                         $0

11 Dividends declared but unpaid (p.10, col.11, line 25)                                $0                         $0

12 Unpaid special assessments receivable                                                $0                         $0

13 Reinsurance recoverable on paid losses and on paid
   loss adj. expense (p. 18, col. 5 plus p. 19, col. 4)                                 $0                         $0

14 Income tax refund due (Sch. M, p. 20, line 2)                                        $0                         $0

15 Reinsurance commission receivable                                                    $0                         $0

16 *Aggregate write-ins                                                                 $0                         $0

17 Total Admitted Assets (total lines 7a through 16)
   (p. 5, col. 4, line 18)                                                              $0                         $0

   *List of write-ins on page 22



                                                                -3-
                                                                                                    Year


                                                                             Insurance Company



                                                                            Liabilities & Surplus


                                                                                     (1)                      (2)
                                                                                Current Year               Prior Year

 1 Net unpaid losses (p.15, line 1)                                                            $0                       $0

 2 Net unpaid loss adjustment expense (p.15, line 2)                                           $0                       $0

 3 Unpaid salaries                                                                             $0                       $0

 4 Unpaid commissions                                                                          $0                       $0

 5 Balance due on borrowed money                                                               $0                       $0

 6 Interest due on borrowed money                                                              $0                       $0

 7 Net unearned premium reserve (p.16, col. 6)                                                 $0                       $0

 8 Funds held but not yet remitted on combination policies (p.24, line 6)                      $0                       $0

 9 Reinsurance premium payable                                                                 $0                       $0

10 Income taxes payable (Sch. M, p. 20, line 5)                                                $0                       $0

11 Payroll taxes owed by company                                                               $0                       $0

     Write-ins:

12                                                                                             $0                       $0

13                                                                                             $0                       $0

14 *Aggregate write-ins                                                                        $0                       $0

15 Total Liabilites                                                                            $0                       $0

16 Surplus (assets less liabilities)                                                           $0                       $0

17 Total (line 15 plus line 16) (p. 5, col.4, line 18)

     (should equal admitted assets)                                                            $0                       $0



     *List of remaining write-ins on page 22

                                                                                     -4-
     _______________________________ Insurance Company                               Year ________


     Statement of Income                                                  (1)             (2)
                                                                     Current year      Prior Year
     Underwriting Income


 1 Net Premiums Earned (P. 17, Col. 8)                                          $0                  $0


     Deductions


 2   Net Losses Incurred (P. 18, Col. 12)                                       $0                  $0
 3   Net Loss Adjustment Expense Incurred (P. 19, Col. 11)                      $0                  $0
 4   Net Commission Expense (Sch. L on P. 20, L. 6)                             $0                  $0
 5   Other Underwriting Expense Incurred (P. 21, L. 18, Col. 4)                 $0                  $0
 6   Total Underwriting Deductions (Lines 2+3+4+5)                              $0                  $0


 7 Net Underwriting Gain or (Loss) (Lines 1-6)                                  $0                  $0


     Investment Income


 8 Net Investment Income Earned (P. 14, Col. 6)                                 $0                  $0
 9 Net Realized Capital Gains or (Losses)(P. 13, Col. 5)                        $0                  $0
10 Net Investment Gains or (Losses) (Lines 8+9)                                 $0                  $0


     Other Income


11   Rental Income (P. 12, Col. 9)                                              $0                  $0
12   Commissions on Combination Policies (P. 1, L. 20)                          $0                  $0
13   Miscellaneous Income or (Losses) (a)                                       $0                  $0
14   Total Other Income (Lines 11+12+13)                                        $0                  $0


15 Net Income Before Income Taxes (Lines 7+10+14)                               $0                  $0


16 Income Taxes Incurred (Sch. M on P. 20, L. 7)                                $0                  $0


17 Net Income (Loss) (Lines 15-16)                                              $0                  $0


_________________________________________________________________________________________

(a) Miscellaneous Income and (Losses)

         Aggregate Write-ins from Page 1, Line 22                               $0
     + Aggregate Write-ins from Page 3, Line 16(CY)                             $0
     -   Aggregate Write-ins from Page 3, Line 16(PY)                           $0


                             Miscellaneous Income                               $0
                                                                  P. 6, L. 13


                                               -6-
                                                                                                                                                        Year

                                                                    Insurance Company
                                                                                                          Analysis of Assets
                                                                               (1)                                 (2)                                   (3)                               (4)
                                                                            Ledger                           Non-Ledger                           Assets not                      Admitted Assets
                                                                            Assets                            Assets ( b )                      Admitted ( c )                        Col. 1+2-3


   1   Cash in company's office                                                          $0                                 $0                                 $0                                  $0
   2   Cash deposited in checking account                                                $0                                 $0                                 $0                                  $0
   3   Other cash deposits                                                               $0                                 $0                                 $0                                  $0
   4   Bonds                                                                             $0                                 $0                                 $0                                  $0
   5   Mutual Funds                                                                      $0                                 $0                                 $0                                  $0
   6   Preferred Stock                                                                   $0                                 $0                                 $0                                  $0
   7   Common Stock                                                                      $0                                 $0                                 $0                                  $0
   8   Real Estate                                                                       $0                                 $0                                 $0                                  $0
   9   Agents' balance/
       uncollected premiums (a)                                                          $0                                 $0                                 $0                                  $0
 10    Due and accrued investment income                                                 $0                                 $0                                 $0                                  $0
 11    Dividends declared but unpaid                                                     $0                                 $0                                 $0                                  $0
 12    Reinsurance recoverable on paid
       losses and on paid loss adj. expense                                              $0                                 $0                                 $0                                  $0
 13    Income tax refund due                                                             $0                                 $0                                 $0                                  $0
 14    Reinsurance commission receivable                                                 $0                                 $0                                 $0                                  $0
 15    Furniture and fixtures                                                            $0                                 $0                                 $0                                  $0
 16    EDP equipment                                                                     $0                                 $0                                 $0                                  $0
 17    Write-ins                                                                         $0                                 $0                                 $0                                  $0
       *
 18       Totals                                                                         $0                                 $0                                 $0                                  $0
                                                                    P2, L36                                                                                                   P3,C1,L17
*List of write-ins on page 23

NAMICO and NAMICO bank stock may be shown as either ledger or non-ledger, but must be non-admitted.

( a ) Traditionally, companies have treated agents' balances as ledger (col.1) and uncolledted premiums due from policyholders as non-legder (col.2).

( b ) Non-ledger assets should include excess of amortized over book value and the increase in market value of mutual funds, common stock and preferred stock over actual cost to company.

( c ) Asset not admitted shall include excess of book value over amortized value of bonds and the excess of actual cost over market value of mutual funds, common stock and preferred stock.



                                                                                                                                                        -5-
                                                                                                                                                        Schedule A          Part One
                                                                                                                                                            Year

                                                                                                Insurance Company

                                                                                                    Cash in Banks or Savings and Loans

                                                                 (1)              (2)                 (3)              (4)                (5)                 (6)                (7)

                                                                                                    Checks                              Interest

                                                                                                    Issued                            Received on           Interest

                                                                                Account             but not            Net             Deposits             Accrued            Interest

          Name of institution and Location                  Interest            Balance             Cashed          Balance            during CY           12/31/CY            Accrued

            (list institution alphabetically)                Rate               12/31/CY            12/31/CY        (Col. 2-3)            (a)                 (b)              12/31/PY

Checking Accounts:                                                                         $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                                                           $0                  $0                $0                $0                  $0                 $0
                                                Subtotal                                   $0                  $0                $0                $0                  $0                 $0
                                                                                                                    P3, L2

(a) Include both interest actually received and interest added
    to account balance during current year.
(b) Do not include interest already reflected in account balance of column 1.
                                                                                                      -7-
                                                                                                                                                                    Schedule A
                                                                                                                                                                     Part Two
                                                                                                                                                   Year

                                                                                             Insurance Company

                                                                                             Cash in Banks or Savings and Loans
                                                                                                (certificates of deposit/other)

                                                                   (1)            (2)            (3)             (4)               (5)              (6)                 (7)
                                                                                               Checks                           Interest
                                                                                               Issued                        Received on          Interest
             Name of institution and Location                                   Account        but not           Net           Deposits          Accrued             Interest
                (list institution alphabetically                Interest        Balance        Cashed          Balance         during CY         12/31/CY            Accrued
               and designate type of account)                     Rate          12/31/CY      12/31/CY        (Col. 2-3)           (a)              (b)              12/31/PY
Other Cash Deposits:                                                                    $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                                                        $0              $0             $0                  $0                $0                 $0
                                                     Subtotal                           $0              $0             $0                  $0                $0                 $0
                                   Total (Parts One and Two)                            $0              $0 XXXX                            $0                $0                 $0
                                                                                                             P3, L3         Sch. F, Col. 1    Sch. F, Col. 4      Sch. F, Col. 4
(a) Include both interest actually received and interest added                                                              (page 1, line 12)
      to account balance during current year.
(b) Do not include interest already reflected in account balance of column 1.
                                                                                                                 -8-
                                                                                                                                                                                                Schedule B


                                                                                                                                                                             Year

                                                       Insurance Company

                                                                                          Bonds

               (1)               (2)           (3)       (4)       (5)        (6)           (7)           (8)             (9)              (10)            (11)                  (12)                (13)
                                  Interest              Mat.      Date                                                                   Interest                                Change in
                                                        Date       of                                                    gross                                                   Amortized Value
                                             Payment            Purchase                                                amount          accrued          accrued                       During Year
           Description                        Dates     mo./      mo./     Amortized       Face         Actual          received          12/31            12/31            Increase             Decrease
    (be complete and accurate)   Rate        day/mo.    year      year       Value         Value         Cost          _________           CY               PY                   (+)                 (-)

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

                                                                                     $0            $0            $0              $0               $0               $0                     $0                $0

Pd. For Accrued Interest                                                             $0            $0            $0              $0               $0               $0                     $0                $0

Interest on Bonds Sold                                                               $0            $0            $0              $0               $0               $0                     $0                $0

Total                                                                                $0            $0            $0              $0               $0               $0                     $0                $0
                                                               P3,L4                                                  P1,L11          Sch. F           Sch. F           Sch. F                 Sch. F
                                                                                                                                      Col. 4           Col. 5           Col. 2                 Col. 3




                                                                                           -9-
                                                                                  Insurance Company                                                                                  Schedule C
                                                                                                                  Stocks and Mutual Funds                                               Year
Part I - Stocks and Mutual Funds Held at Year
                 (1)                       (2)            (3)             (4)         (5)             (6)                    (7)                     (8)               (9)              (10)               (11)              (12)
                                                                                                                         Aggregate                Prior Year
                                                                                                                        Unrealized               Aggregate           Cash                               Dividends         Dividends
                                                                       Number                                        Capital Gains (+)        Unrealized Capital    Dividends        Dividends          Declared          Declared
                                        Ticker          Date             of                       Market Value          & Losses (-)             Gains (+) &        Received         Reinvested            but               but
       Name of Corporation              Symbol         Acquired        Shares         Cost         12/31/CY         (Col. 5 minus Col. 4)         Losses (-)        During CY         During CY         Unpaid CY         Unpaid PY
           Mutual Funds
1.                                                                                           $0              $0                          $0                    $0               $0                $0                $0                $0
2.                                                                                           $0              $0                          $0                    $0               $0                $0                $0                $0
3.                                                                                           $0              $0                          $0                    $0               $0                $0                $0                $0
4.                                                                                           $0              $0                          $0                    $0               $0                $0                $0                $0
5.                                                                                           $0              $0                          $0                    $0               $0                $0                $0                $0
6.                                                                                           $0              $0                          $0                    $0               $0                $0                $0                $0
7.                                                                                           $0              $0                          $0                    $0               $0                $0                $0                $0
8. Total Mutual Funds (a)                                                                    $0              $0                          $0                    $0               $0                $0                $0                $0

           Preferred Stock
9.                                                                                           $0              $0                          $0                    $0               $0                $0                $0                $0
10.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
11.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
12.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
13.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
14.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
15.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
16. Total Preferred Stock (b)                                                                $0              $0                          $0                    $0               $0                $0                $0                $0

           Common Stock

17.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
18.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
19.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
20.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
21.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
22.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
23.                                                                                          $0              $0                          $0                    $0               $0                $0                $0                $0
24. Total Common Stock (b)                                                                   $0              $0                          $0                    $0               $0                $0                $0                $0

25. Total Mutual Funds and
Stocks (d)                                                                                   $0              $0                          $0                    $0               $0                $0                $0                $0
                                                                                                                                                                                                       Sch. F, Col 4     Sch. F, Col 5
(a) Page 3, Line 5 should equal the market value (col. 6) of Total Mutual Funds.
(b) Page 3, Line 6 should equal the market value (col. 6) of Total Preferred Stock.
( c) Page 3, Line 7 should equal the market value (col. 6) of Total Common Stock.
(d) Add Line 8+Line 16+Line 24                                                                                              -10-
                                                                              Insurance Company                                            Year                                  Schedule C
                                                                              Stocks and Mutual Funds                                                                            (continued)
Part II - Stocks and Mutual Funds Sold During
                (1)                        (2)                   (3)                                      (4)                               (5)                 (6)                     (7)


                                                                                                                                                           Unrealized             Cash Dividends
                                                              Number                                                                                    Capital Gains (+)            Received
                                         Date                    of                                                                     Market Value       & Losses (-)            and Reinvested
      Name of Corporation              Disposed                Shares                                    Cost                            12/31/PY      (Col. 5 minus Col. 4)         During CY
1.                                                                                                                                 $0             $0                        $0                  $0
2.                                                                                                                                 $0             $0                        $0                  $0
3.                                                                                                                                 $0             $0                        $0                  $0
4.                                                                                                                                 $0             $0                        $0                  $0
5.                                                                                                                                 $0             $0                        $0                  $0
6.                                                                                                                                 $0             $0                        $0                  $0
7.                                                                                                                                 $0             $0                        $0                  $0
8. Totals                                                                                                                          $0             $0                        $0                  $0
Part III - Stocks and Mutual Funds Purchased and Sold During
                (1)                        (2)                   (3)                                      (4)
                                                                                                   Cash Dividends
                                                               Date                            Received & Reinvested
      Name of Corporation            Date Acquired           Disposed                                During CY
9.                                                                                                                                 $0
10.                                                                                                                                $0
11.                                                                                                                                $0
12.                                                                                                                                $0
13.                                                                                                                                $0
14.                                                                                                                                $0
15. Totals                                                                                                                         $0


16. Unrealized Capital Gain or Loss on Secruities Currently Held (P.10, L.25, Col. 7 minus P.10, L.25, Col 8):                                                                                  $0
17. Reversal of Previously Recognized Unrealized Capital Gain or Loss on Securities Sold During Current Year (P.11, L.8, Col. 6)                                                                $0
18. Net Unrealized Capital Gain or Loss (P.11. L.16 minus P. 11, L 17):                                                                                                                         $0
Total Dividends Received or Reinvested During Current Year
19. P.10, L.25, Col. 9:                             $0
20. +P.10, L.25, Col. 10:                           $0
21. + P.11, L.8, Col. 7:                            $0
22. + P.11, L.15, Col. 4:                           $0
23. Total                                          $0

                                                                                                         -11-
                                                                                                                                                                  Schedule D


                                                                                                                                                    Year




                                                                       Insurance Company

                                                                                              Real Estate

                   (1)                          (2)            (3)              (4)                    (5)            (6)             (7)             (8)            (9)               (10)


                                               Date                                                                                                                                  Admitted
                                            Acquired or                                        Encumbrances       Encumbrances                                     Rental            Value of
                                           Improvement       Useful           Actual               December 31    December 31     Depreciation    Accumulated      Income           Real Estate
           Description (a) (b)                 Made            Life            Cost                   (CY)            (PY)           (CY)         Depreciation    Received          (col. 4-5-8)

                                                                                       $0                    $0              $0              $0              $0                $0               $0
                                                                                       $0                    $0              $0              $0              $0                $0               $0
                                                                                       $0                    $0              $0              $0              $0                $0               $0
                                                                                       $0                    $0              $0              $0              $0                $0               $0
                                                                                       $0                    $0              $0              $0              $0                $0               $0
                                                                                       $0                    $0              $0              $0              $0                $0               $0
                                                                                       $0                    $0              $0              $0              $0                $0               $0
Total                                                                                  $0                    $0              $0              $0              $0                $0               $0
                                                                                                                                    P2,L28                         P1,L14             P3,L8
(a) Capital improvements should be shown on separate lines and depreciated over their useful life.                                                                 P6,L11
(b) Land should be listed separately from the home office building, since it is not depreciable.




                                                                                                                     -12-
                                                                                                                                  Schedule E
                                                                                                                           Year
                                                            Insurance Company

                                                          Realized Capital Gains and Losses

                                       (1)          (2)                     (3)                 (4)                 (5)
                                                                                                              Net Realized
                                     Date          Date                   Cost or          Consideration   Capital Gains (Loss)
                Asset              Purchased       Sold                 Other Basis          Received         Col. 4-Col. 3
Bonds:                                                                                $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
Real Estate:                                                                          $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
Mutual Funds:                                                                         $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
Preferred Stocks:                                                                     $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
Common Stocks:                                                                        $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
Non-Admitted Investments:                                                             $0              $0                     $0
                                                                                      $0              $0                     $0
                                                                                      $0              $0                     $0
Totals:                                                                               $0              $0                     $0
To be completed only if investments have been sold or have matured during the year.                            P. 6, L.9

                                                                           -13-
                                                                    Insurance Company

                                                                                  Investment Income Earned


                                    (1)               (2)                   (3)              (4)                     (5)                 (6)

                               Interest

                            & Dividends         Accumulation          Amortization                 Interest & Dividends

                              Received             of Bond               of Bond                    Due & Accrued                    Investment

                               During              Discount             Premium            Current                  Prior          Income Earned

         Assets                Year(a)         (Sch. B., Col. 12)    (Sch. B., Col.13)      Year                    Year         (Columns 1+2-3+4-5)

Cash on Deposit                           $0                  $0                   $0                  $0                   $0                     $0
Bonds                                     $0                  $0                   $0                  $0                   $0                     $0
Notes Receivable                          $0                  $0                   $0                  $0                   $0                     $0
Mutual Funds                              $0                  $0                   $0                  $0                   $0                     $0
Preferred Stocks                          $0                  $0                   $0                  $0                   $0                     $0
Common Stocks                             $0                  $0                   $0                  $0                   $0                     $0
Write-ins:                                $0                  $0                   $0                  $0                   $0                     $0
Total                                     $0                  $0                   $0                  $0                   $0                     $0
                                                                                                                                     P. 6, L. 8
(a) Net of any accrued interest purchased.

(b) List of write-ins on page 22.


                                                                                            -14-
                                                                      Schedule G
                                                                      Year

                                                       Insurance Company

                                                       Net Unpaid Losses & Adjusting Fees


1   Unpaid Losses
    a. Reported and adjusted                                     $0

    b. Reported but not adjusted                                 $0

    c. Incurred but not reported (at year end)                   $0

    d. Reinsurance recoverable on unpaid
       reported losses                                           $0

    e. Reinsurance recoverable on incurred
       but not reported                                          $0

       Subtotal (a+b+c-d-e)                                                         $0 (Page 4, line 1)




2   Unpaid Adjusting Fees
    a. On reported and adjusted losses                           $0

    b. On reported but not adjusted losses                       $0

    c. On incurred by not reported losses (estimate)             $0

    d. Reinsurance recoverable on unpaid                         $0

       adjusting fees
       Subtotal (a+b+c-d)                                                           $0 (Page 4, line 2)




3   Net unpaid losses & adjusting fees                                              $0




                                                                             -15-
                                                                                                                           Schedule H


                                                                                                               Year

                                                                        Insurance Company

                                                                        Unearned Premium Schedule


                                        (1)               (2)              (3)          (4)              (5)                   (6)




                                                        Ceded

                                      Gross          Reinsurance           Net         Gross

             Line of                Premiums            Premium          Premiums      Total        Reinsurer's                Net

            Business                 In Force           In Force         In Force     Unearned        Unearned             Unearned (b)

Fire                                          $0                   $0            $0            $0               $0                        $0
Other Peril(s)                                $0                   $0            $0            $0               $0                        $0
Wind                                          $0                   $0            $0            $0               $0                        $0
Total                                         $0                   $0            $0            $0               $0                        $0

                                                                                                                      P4, L7

Complete either columns 1,2,3 and 6, or 1,4,5 and 6, depending on whether your reinsurer provides ceded reinsurance premiums

in force or reinsurer's share of unearned premium.




(a) May be combined with fire.

(b) Amount is derived from company's own calculation.

                                                                          -16-
                                                                                                                                                        Schedule I


                                                                                                                            Year

                                                                           Insurance Company

                                                                                     Net Premium Earned

                 (1)                           (2)              (3)            (4)              (5)                   (6)                   (7)             (8)


                                                                               Net              Net                  Net                                    Net
                                           Premiums         Reinsurance     Premiums         Unearned             Unearned                               Premiums
              Line of                        Written          Ceded          Written         Premium              Premium               Policy            Earned
             Business                          (b)             (c)           Col. 2-3           PY                   CY                     Fees        Col. 4+5-6+7

Fire                                                   $0             $0             $0               $0                     $0                    $0                  $0
Other Peril(a)                                         $0             $0             $0               $0                     $0                    $0                  $0
Wind                                                   $0             $0             $0               $0                     $0                    $0                  $0
Total                                                  $0             $0             $0               $0                     $0                    $0                  $0
                                                                                          P4, Col. 2, L7   P4, Col. 1, L7              P1, L3             P6, L1
(a) May be included with Fire
Advance premium should be included in Columns 2 and 6


(b)                                                                                                        (c)
Page 1, Line 2(a+b)                                                                  $0                    Current year reinsurance
Uncollected Premium CY                                          +                    $0                     premium payable (Page 4, Col.1, Line 9)                         $0
Uncollected Premium PY                                          -                    $0                    Current year remittances:
                                                                                                                 a. Proportional (Page 1, Line 6)            +              $0
Returned on cancellations (Page 1, Line 8)                      -                    $0                          b. Excess, Catastrophe & Facultative
Assumed reinsurance premium (Page 1, Line 4)                    +                    $0                             (Page 1, Line 7)                         +              $0
Premiums written                                                                     $0                    Prior year reinsurance premium payable
                                                                                                                 (Page 4, Col. 2, Line 9)                    -              $0
Please complete footnotes (b) and ( c ).                                                                   Net Reinsurance Ceded                                            $0

                                                                                               -17-
                                                                                                                                                                                        Schedule J


                                                                                                                                                                             Year

                                                       Insurance Company

                                                                                                         Losses Incurred

          (1)          (2)                  (3)             (4)            (5)              (6)              (7)            (8)             (9)            (10)           (11)              (12)


                                                                       Reinsurance      Reinsurance         Net           Unpaid          Unpaid        Reinsurance    Reinsurance          Net
                                      Salvage &                        Recoverable      Recoverable        Losses         Losses          Losses        Recoverable    Recoverable        Losses
        Line of      Losses          Subrogation        Reinsurance      on Paid          on Paid         Paid Col.       Current          Prior         on Unpaid      on Unpaid        Incurred
       Business        Paid           Received           Recovered      Losses CY        Losses PY        2-3-4-5+6     Year (Gross)    Year(Gross)     Losses CY      Losses PY      Col. 7+8-9-10+11

Fire                          $0                  $0              $0               $0               $0             $0              $0              $0             $0             $0                 $0
Other Perils(a)               $0                  $0              $0               $0               $0             $0              $0              $0             $0             $0                 $0
Wind                          $0                  $0              $0               $0               $0             $0              $0              $0             $0             $0                 $0
Total                         $0                  $0              $0               $0               $0             $0              $0              $0             $0             $0                 $0
                  P2, L2           P2, L5                                                                                   (b)            (c)              (d)            (e)            P6, L2


(a) May be included with fire.
(b) Schedule G, Lines 1a+1b+1c from CY statement.
(c) Schedule G, Lines 1a+1b+1c from PY statement.
(d) Schedule G, Line 1d+1e from CY statement.
(e) Schedule G, Line 1d+1e from PY statement.




                                                                                           -18-
                                                                                                                                                               Schedule K


                                                                                                                                                     Year

                                                    Insurance Company

                                                                                   Loss Adjustement Expense (LAE) Incurred

          (1)             (2)            (3)             (4)            (5)            (6)            (7)            (8)            (9)           (10)             (11)


                                                     Reinsurance    Reinsurance       Net                                       Reinsurance    Reinsurance         Net
                                                     Recoverable    Recoverable       LAE         Unpaid LAE     Unpaid LAE     Recoverable    Recoverable         LAE
        Line of           LAE        Reinsurance       on Paid       on Paid        Paid Col.     Current Year   Prior Year      on Unpaid      on Unpaid        Incurred
        Business        Paid (a)     Recovered         LAE CY         LAE PY         2-3-4+5        (Gross)       (Gross)         LAE CY         LAE PY       Col. 6+7-8-9+10

Fire                            $0             $0              $0             $0             $0             $0             $0             $0             $0                 $0
Other Perils(a)                 $0             $0              $0             $0             $0             $0             $0             $0             $0                 $0
Wind                            $0             $0              $0             $0             $0             $0             $0             $0             $0                 $0
Total                           $0             $0              $0             $0             $0             $0             $0             $0             $0                 $0
                     P2, L9                                                                           (c)           (d)             (e)            (f)           P6, L3


(a) LAE should include the loss adjuster's salary as well as the claims division's salaries.
(b) May be combined with fire.
(c) Schedule G, Lines 2a+2b+2c from CY statement.
(d) Schedule G, Lines 2a+2b+2c from PY statement.
(e) Schedule G, Line 2d from CY statement.
(f) Schedule G, Line 2d from PY statement.




                                                                                     -19-
Net Commission Expense                                                        Year
                                                                                                   Schedule L

Commisions incurred on:
1. Direct (a)                                                            $0
2. Reinsurance Assumed                                                   $0
3. Ceding reinsurance commission (b)                                     $0
4. Contingent-net                                                        $0
5. Policy and membership fees                                            $0

                      Net commission expense
                            (1+2-3+4+5)                                                       $0
                                                                                     P6, L4
     (a) Commissions paid (or retained by agent)
         + Unpaid commissions (CY) (P4, L4, Col. 1)
         - Unpaid commissions, prior year (PY) (P4, L4, Col. 2)

     (b) Ceding commissions received (or retained by company)
         + Ceding commissions receivable (CY) (P3, L15, Col.1)
         - Ceding commissions receivable (PY) (P3, L15, Col. 2)




                                                                                                   Schedule M

Income Taxes Incurred

1.   Income Tax Refund Received (P 1, L21)                               $0
2.   Income Tax Refund Due (CY) (P3, L 14, Col. 1)                       $0
3.   Income Tax Refund Due (PY) (P3, L 14, Col. 2)                       $0
4.   Income Taxes Paid (P2, L32)                                         $0
5.   Income Taxes Payable (CY) (P4, L10, Col. 1)                         $0
6.   Income Taxes Payable (PY) (P4, L10, Col. 2)                         $0

7. Income Taxes Incurred (1+2-3-4-5+6)                                                        $0
                                                                              P6, L16

                                                                  -20-
    _______________________________Insurance Company                                         Year_________

                                                                                             Schedule N
    Other Underwriting Expenses
                                                                        (1)                (2)       (3)          (4)
                                                                                        Unpaid    Unpaid
    Expense                                                            Expense          Expense   Expense     Expense
                                                                          Paid            (CY)      (PY)       Incurred
                                                                           (a)             (b)       (c)     Col. (1+2-3)
 1 Legal and Auditing Expense                                                   $0             $0        $0            $0
 2 Salaries and Expenses of Officers, Directors and Committees                  $0             $0        $0            $0
 3 Salaries of Offfice Employees                                                $0             $0        $0            $0
 4 Premium on Officers' Bonds                                                   $0             $0        $0            $0
 5 General Office Expense including Rent                                        $0             $0        $0            $0
 6 Taxes and Repairs on Real Estate                                             $0             $0        $0            $0
 7 Insurance Department Licenses and Fees                                       $0             $0        $0            $0
 8 Payroll Taxes                                                                $0             $0        $0            $0
 9 Advertising, Printing, and Stationery                                        $0             $0        $0            $0
10 Telegraph, Telephone, Express, and Postage                                   $0             $0        $0            $0
11 National and State Association Dues                                          $0             $0        $0            $0
12 Fire Department Fees                                                         $0             $0        $0            $0
13 Agents' Balances Charged Off                                                 $0             $0        $0            $0
14 Interest on Borrowed Money                                                   $0             $0        $0            $0
15 Purchase of Non-ledger Asset                                                 $0             $0        $0            $0
16 Annual Depreciation Expense                                                  $0             $0        $0            $0
17 * Aggregate Write-ins (itemize)                                              $0             $0        $0            $0
                                                                     ___________ ___________ ___________ ___________
18 Total Expenses                                                               $0             $0        $0            $0
                                                                                                            P. 6, L. 5
(a) The amounts in this column come from Page 2, Lines 10 through 23, 25, 27, 28 and 32.
(b) The amounts in this column come from liabilities on Page 4 of current year's statement.
(c) The amounts in this column come from liabilities on Page 4 of the prior year's statement.

*   List of write-ins on Page 23
                                                                 -21-
Write-in Page                                            Year


Write-ins for Receipt of Ledger Assets:


1.                                                0.00
2.                                                0.00
3.                                                0.00
4.                                                0.00
5. Total (P1,L22)                                $0.00


Write-ins for Disbursements:


1.                                               $0.00
2.                                               $0.00
3.                                               $0.00
4.                                               $0.00
5. Total (P2,L33)                                $0.00


Write-ins for Assets:


1.                                               $0.00
2.                                               $0.00
3.                                               $0.00
4.                                               $0.00
5. Total (P3,L16)                                $0.00


Write-ins for Liabilities:


1.                                               $0.00
2.                                               $0.00
3.                                               $0.00
4.                                               $0.00
5. Total (P4,L14)                                $0.00

                                          -22-
Write-in Page                                   Year


Write-ins for Analysis of Assets:
                                    1                  2           3           4
1.                                      $0.00              $0.00       $0.00       $0.00
2.                                      $0.00              $0.00       $0.00       $0.00
3.                                      $0.00              $0.00       $0.00       $0.00
4.                                      $0.00              $0.00       $0.00       $0.00
5.       Total (P5,L17)                 $0.00              $0.00       $0.00       $0.00


Write-ins for Investment Income:


1.                                      $0.00
2.                                      $0.00
3.                                      $0.00
4.                                      $0.00
5.       Total (Sch. F)                 $0.00


Write-ins for Expenses:
                                    1                  2           3           4
     1                                  $0.00              $0.00       $0.00       $0.00
     2                                  $0.00              $0.00       $0.00       $0.00
     3                                  $0.00              $0.00       $0.00       $0.00
     4                                  $0.00              $0.00       $0.00       $0.00
     5 Total (P21, L17)                 $0.00              $0.00       $0.00       $0.00
                                                                                     Year

To be completed by those companies which write a combination policy with any other company and also collect
premium on behalf of that company. This also applies to those companies which maintain receipts in a specially
designated account.



1.    Total wind and/or liability premiums held on behalf of others but

      not yet remitted at the prior year end.                                                                    $0


2.    Total amount of wind or liability premiums received by company

      (include handling fees, commisions, service fees, or other

      allowances).                                                                                               $0


3.    Handling fees, service fees, commissions, or other allowances

      which your company is paid and/or entitled to retain (included in

      item 2 above).

      a. received directly from wind or liability carrier                                                        $0
      b. retained from gross receipts                                                                            $0


4.    Total amounts remitted by company to:

      a. wind/liability carrier                                                                                  $0
      b. agents                                                                                                  $0
      c. policyholders on returns or cancellations                                                               $0


5.    Amount yet to be remitted at year end to:

      a. wind/liability carrier                                                                                  $0
      b. agents                                                                                                  $0
      c. policyholders on returns or cancellations                                                               $0


6.    Total held on behalf of others, but not yet remitted at the current year end

      (line 5a + 5b + 5c) (P4,L8)                                                                                $0




                                                                     -24-
                                                        General Interrogatories                      Year _________

1.    Is the assessment liability of the members clearly defined in the bylaws?


2.    Do the members pay survey, membership, or policy fees at the time the
      policy is issued? If yes, what is the fee per policy?


3.    Were any special assessments made during the year?


4.    Have all losses been adjusted in accordance with the provisions of the policy?


      Please provide, unless previously submitted, a complete copy of any reinsurance agreements that were in effect during
      the current year.


5.    What salaries were paid during the past year to the following officers?             Pres.                               hours per week
                                                                                          V.P.                                hours per week
                                                                                          Sec.                                hours per week
                                                                                          Treas.                              hours per week


6.    What, if any, commissions were paid during the past year to                         Pres.
      each of the following officers in addition to salary?                               V.P.
                                                                                          Sec.
                                                                                          Treas.


7.    How often do Directors meet?
      Amount of Directors' fees per meeting?
      Mileage reimbursement per mile


8.    Please provide a description, in the form of an attachment, of the property that each director has insured with the
      company, along with the amount of coverage on such property. The attachment should include the following information:
      director's name, description of property, and coverage amount.


      In order to keep the response to this question confidential, please provide the response in an attachment separate
      and apart from the annual statement. As with all general interrogatories, the annual statement will not be considered
      filed with the Illinois Department of Insurance until a response to this general interrogatory is received.



9.    How many employees does the company have? (Include only those employees
      whose salaries are included on Line 13 of Page 2.)
                                                Full time (32 hrs. or more per week)
                                                Part-time (less than 32 hrs. per week)


10.   Do the officers/employees furnish surety bonds?
      Please list:
      Name of Officer/Employee                           Position                                  Amt. of Bond at 12/31/CY




      Name of insurance company (surety) issuing bond:
      Is your bond a blanket bond?
      If yes, is it a commercial blanket or blanket position bond?
      Does the above list of bonded employees include all employees who
       handle the company's funds?


                                                                                   -25-
                            General Interrogatories continued
      Does the surety bond coverage at December 31 of the current year on
       officers/employees meet the minimum required amount based on
       total admitted assets as shown on page 3 of this statement?
      If not, has the coverage been increased?
      If yes, to what amount?
      Please remit a copy of the rider effecting the increase in coverage as
       soon as available.


11.   Total number of policies-in-force at December 31 of the current year.


12.   Does your company insure more than 100 policyholders?
      Less than 200?


13.   What is your company's gross insurance-in-force?


14.   Are the checks issued by the company countersigned by one of the officers?


15.   Are the securities of the company kept in a safe, fireproof place as
      required by rules and regulations issued by the Illinois Department of
      Financial and Professional Regulation, Division of Insurance?


16.   Does your company retain duplicate deposit slips covering all bank deposits?
      Are all checks listed in detail?


17.   How many Directors are producing agents of your company?
      How many producing agents does your company retain that are not Directors?


18.   Does the company share office space with an agent or agency?
      If yes, is there a written agreement?
      Does this agreement include terms for sharing of office expenses?


19.   What percentage of your risks are written for:                                           six months?
                                                                                               one year?
                                                                                               two years?
                                                                                               three years?
                                                                                               four years?
                                                                                               five years?


20.   What commission rate does your company pay during each
      year of the policy period?                                                               first year?
                                                                                               second year?
                                                                                               third year?


21.   What types of property does your company insure?


22.   What type of risk does your company cover? (fire, extended coverage,
      windstorm, etc.)


23.   Do you write a combination policy with any other company?
      If yes, give name of company and complete page 24.


24.   Does your company allow insureds to pay premiums on an installment basis?
      If yes, approximately what percentage of your business is billed on this basis?


25.   What is the lowest percent of the value of the property that the company
      insurers?
                                                                                        -26-
                           General Interrogatories continued
26.   How often does you company reassess the value of the property insured?


27.   Has any change been made during the year of this statement in the policy,
      articles of incorporation and bylaws of your company?
      If not previously filed, furnish the Division of Insurance with this information.


28.   Do you have a formal agents agreement?
      If yes, does this agents agreement state that ownership of the renewals
      belongs to your company or to the agent?


29.   Are any of the risks written by your company reinsured by other companies?


30.   If company carries annual aggregate excess loss reinsurance, give name
      of the company assuming such liability.
      What is the attachment or inception point?
      What percentage does the reinsurer pay once the maximum
      attachment or inception point has been reached?


31.   In what territory does your company have the authority to write? If county
      give name of counties. If township company, give name of townships.




32.   Is your company writing outside this territory?


33.   Is the company audited annually or periodically by an outside Certified
      Public Accounting firm?
      If yes, give name, address, and phone number.




34.   Name, address and phone number of person who prepared statement.




Section 10(2) states, "No Farm Mutual Insurance Company authorized to write the kinds of insurance enumerated in
Section 5 of this act may expose itself to any loss of any one risk in an amount in excess of $20,000.00 plus 10% of its
policyholders' surplus in excess of $20,000.00. This Section defines a single risk as "all real and personal property in one
fixed location and not separated by 50 feet." Also, "A Farm Mutual Insurance Company insuring against the perils of wind
or hail must have and maintain catastrophic reinsurance which limits the company's exposure to any one loss occurrence to 20%
of its policyholders' surplus." Whereas, "as regards the peril of wind or hail, the term (loss occurrence) shall mean all losses
occasioned by tornadoes, cyclones, wind storms, hurricanes, or hail stones arising from the same atmospheric disturbance and
occuring during any continuous period of not less than 48 hours."


Is your company fully in compliance with the above provision s of the 1986 Farm Mutual Act as pertains to limitations of risk?
Yes_____ No______ If no, please explain fully.



                                                                 -27-
                                                                                                                        Year
State of Illinois


County of


                                                               President, and


Secretary of the


Insurance Company, being duly sworn, each for himself deposes and says that they are the above described officers of the
company, and that the foregoing Annual Statement, with the Schedules and explanations herein contained, annexed or referred
to, are a full and correct Statement of all the Assets, Liabilities, Receipts, and Disbursements, and of the condtion and affairs of said
Company on the said                                day of                              , and for the period ended on that day, as the same were
in fact and as the same are shown by the books of the Company, and that the foregoing declaration and answers are true,
according to the best of their information, knowledge and belief, respectively.


                                                                                                                                        , President


                                                                                                                                        , Secretary


Suscribed in my presence and sword to before me, by:


                                                                                                                                        , as President


                                                         and                                                                            , as Secretary



                                      of the above named Insurance Company, this                           day of                   ,


WITNESS my hand and seal.
                                                                                                                                        Notary Public


                                                                                                                                        County, Illinois




Important Notice: Disclosure of this information is required under the Illinois Revised Statutes' insurance laws. Failure to provide
information could result in a fine.
                                                                                -28-
                                            Instructions to the Annual Statement


Receipt of Ledger Assets (page 1):
Line 1 -     Must agree with column 1, page 5 of last year's statement.


Line 2 -     Include direct premiums received for new, renewal and annual premiums. Include premiums held by agent
             but not yet submitted to the company.


             Line 2A must show directly written fire, allied lines and other perils. Line 2B must include directly written
             wind premiums. Do not include on this line any wind, liability, or other premium written on a combination
             policy with any other insurer. Special assessments must be disclosed as a write-in item on page 1.


Line 3 -     Fees (per policy charges), including those retained by agents, must be shown on this line.


Line 4 -     Include only premiums received for reinsurance assumed.


Line 6 -     Enter premiums remitted to reinsurer, gross for any ceding commissions, for pro rata reinsurance
             (quota share and surplus share), including both treaty and facultative cessions. Ceding commissions are
             to be reported on Line 18 of Page 1.


Line 7 -     Enter premiums remitted to reinsurer for excess loss, catastrophe and excess facultative reinsurance.


Line 8 -     Enter the amount paid on cancellation or overpayment of premiums. Total of lines 6, 7, and 8 should be
             deducted from line 5. Do not show these items as disbursements on page 2.


Line 12 -    Report the amount of interest received on savings accounts and certificates of deposit in banks and
             savings and loans.


Line 13 -    Report the amount of dividends received or reinvested on mutual funds, common stock and preferred
             stock. Short-term capital gain's dividends and long-term capital gain's dividends shall be included on this
             line.


Line 15 -    Enter the amount of cash received when a ledger asset has been sold or redeemed. For example, the face
             amount of a bond which was redeemed during the year would be entered. Interest received upon
             redemption would be included in line 11 above. An entry would also be made on line 26 of page 2.


Line 16 -    Enter the amount received for the sale of non-ledger assets such as office equipment.


Line 18 -    Enter amount of commission received from reinsurer for ceding premiums to them.


Line 19 -    Enter amount of premiums collected (net of any fees or commissions) for wind, liability or other coverages
             written on a combination policy.


Line 20 -    Enter amount of commission or fees received or retained on combination policies.


Line 21 -    Enter amount of state and federal income taxes received during the year.


Disbursements of Ledger Assets (page 2):


Line 2 -     Enter amount of losses paid to the company’s policyholders.


Line 3 -     Enter amount of reinsurance losses paid to other companies.
                                            Instructions to the Annual Statement


Disbursements of Ledger Assets (page 2) Continued
Line 5 -      Enter amount of cash proceeds from salvage and subrogation.


Line 6 -      Enter all reinsurance payments received. This should include both excess loss payments received as
              well as pro rata loss payments received.


Line 9 -      Adjusting expense should include salaries paid to adjusters.


Line 12 -     The salary of the company's secretary should be included in this line since he/she is an officer of the
              company. Include only those amounts actually disbursed for officers' salaries during the year. Unpaid
              salary expense must be reported on page 4, line 3.


Line 13 -     The salary of the company's secretary should not be included in this line since he/she is an officer of the
              company. Include only those amounts actually disbursed for office employees'' salaries during the year.
              Unpaid salary expense must be reported on page 4, line 3.


Line 18 -     Enter only the employer's share of payroll taxes actually disbursed by the company during the year
              including unemployment and solcial security taxes. Unpaid payroll tax expense must be reported on
              page 4, line 11.


Line 26 -     Enter the book value of ledger assets such as bonds or real estate which were sold during the year.
              This has the effect of removing the item from the company's ledger assets.


Line 28 -     Enter current year depreciation on home office building from Page 12, Column 7.


Line 29 -     Enter the amount of premium remitted to the other company on combination policies.


Line 30 -     Enter the amount of commission paid to agents on combination policies by this company.


Line 31 -     Enter the amount of premiums returned or cancelled on combination policies.


Line 32 -     Enter amount of state and federal income taxes paid during the year.


Assets (page 3):


Page 3 reflects the assets portion of the balance sheet. The first column is to show the amounts of admitted assets
held at December 31 of the current year. These amounts are derived from the Analysis of Admitted Assets on Page 5
The second column contains comparative data from the prior year.


Liabilities & Surplus (page 4):


A liability must be shown for all losses that remain unpaid at the end of the year. Incurred but not reported losses
(IBNR) are losses that occurred before year end but had not been reported to the company. This includes losses that
were subsequently reported prior to the preparation of the annual statement as well as an estimate of any losses
occurring in the current year but remaining unreported. Most companies base this estimate on prior experience.


Unpaid commissions owed to agents must be shown as a liability and not as an offset to agents' balances. Also,
payroll taxes withheld for employees and not yet remitted must be shown as a separate write-in liability.
                                             Instructions to the Annual Statement


Analysis of Assets (page 5):


This page shows the development of the company's admitted assets. All assets are either ledger or non-ledger.
Likewise, they are also either admitted or non-admitted. The ledger asset column should contain all assets listed on the
company's books. The non-ledger column should contain all remaining assets. These often include such items as
interest due, furniture and fixtures, reinsurance recoverable on paid losses, and unpaid premiums due from
policyholders. The non-ledger assets column should also include the increase in the market value of mutual funds,
company stock and preferred stock since the securities were purchased (page 10, col.6, lines 8,16, and 24
respectively (if positive)). Anything not defined as an admitted asset by the Farm Mutual Act of 1986 is inadmissable
and must be listed in Column 3 (Assets Not Admitted). Agents' balances and premium due from policyholders more
than 90 days past due, furniture and fixtures, computer hardware and software, and the excess
of the book value of bonds over their amortized values are all non-admitted assets. Column 3 shall also include the
decrase in market value of mutual funds, common stock and preferred stock since the secururties were purchased
(page 10, col.6, lines 8, 16 and 24 respectively (if negative)).


Bonds must now be admitted at amortized cost.


Statement of Income (page 6)


This statement shows the income generated from of underwriting, investments and other income sources along with
the company's overall profitability. The components of the Statement of Income are derived from the various
schedules contained in the annual statement. Each line of this statement has a reference in parenthesis that shows
where the entry on the line is derived.


Schedule A - Cash (page 7 and 8):
Column 4 of Schedule A includes any interest actually received during the year. Column 5 will include any interest due
on accounts (column 5 should not include interest already reflected in the balances in column 1).


Schedule B - Bonds (page 9):
Amortization of a bond discount or premium in the allocation of the difference between face value of the bond and the
price paid for the bond over the period from purchase to maturity.


A discount is the difference between the bond's purchase price and face value when the purchase price is less than
face value.


A premium is the difference between the bond's purchase price and face value when the purchase price is greater
than the face value.


For example, a $100,000 5-year bond purchased for $95,000 is said to have been purchased at a discount of $5,000.
The investor would have a gain of $5,000 when the bond matured in five years. By amortizing, the company would
recognize $1,000 interest income each year the bond is held instead of all $5,000 in the fifth year. Therefore, in the
second year the amortized value of the bond would be $96,000. That is the amount that would belong in column 6.


Column 9 should include all interest received throughout the year. Any accrued interest that was included in the
purchase price of the bonds should then be subtracted from the total on the line provided (Pd for Accr'd Interest).
Interest on bonds sold (received prior to the date sold) should also be listed on the line provided.


Column 12 should contain the year's amortized discount and column 13 will contain the year's amortized premium.
Schedule C (Pages 10 and 11):


Cost is the amount that the company paid for the security. Market value is the value of the securities at the statement
date or disposal date as reported by the New York Stock Exchange, American Stock Exchange, and the National
Association of Securities Dealers Automated Quotation (NASDAQ) systems or Mutual Fund Quotations.


Schedule D - Real Estate (page 12):


Property and improvement descriptions must be complete. Capital Improvements are to be listed separately. As a
result of the Director's bulletin dated November 8, 2002, depreciation is no longer optional. Any land assets held by
the company should be listed separately and not depreciated. Companies are directed to depreciate the affected
assets by using either a straight-line or a more accelerated method. For those companies that have not depreciated
their home office buildings in the past, the home office building is to be depreciated over the remaining useful life of the
building. The building and some improvments may have different useful lives. Accordingly, depreciation of the
improvements may need to be calculated separately from the building. Improvements, such as replacement of the
roof, heating and air conditioning and land improvements (landscaping, parking lot improvements, etc.) must be
depreciated separely from the home office building over the remaining useful life of the building (see bulletin dated
November 8, 2002). In Column 3, the company should record the original useful life assigned to the asset. The useful
life recognized is the company's starting point for determining depreciation. The original useful life determination will
not change from year to year.


Schedule G - Net Unpaid Losses & Adjusting Fee (page 15):


Line 2D includes reinsurance recoverable on all unpaid loss adjusting fees (I.e., reported and adjusted, reported but
not adjusted, and incurred but not reported).


Schedule I - Net Premium Earned (page 17):


The totals in columns 2 and 3 should match Premiums Written in Footnote (b) and Net Reinsurance Ceded in Footnote
( c ), respectively.


Uncollected Premium CY and Uncollected Premium PY in Footnote (b) should be taken from Page 3, line 6, column 1
and column 2, respectively. Any premiums collected by any agent and not submitted to the company should be
included on page 1, line 2, but not included in Uncollected Premiums CY and Uncollected Premiums PY of Footnote (b).


Schedule J - Losses Incurred (page 18):


Be sure to make the distinction between column 4 (reinsurance recovered) and columns 5 and 6 (reinsurance
recoverable). Columns 5 and 6 are receivables due from your company's reinsurer on losses your company had
paid prior to year end. Columns 10 and 11 represent amounts that will be receivable from reinsurer on losses
incurred but not yet paid at year end.


Schedule K - LAE (page 19):


Loss adjustment expenses should include the salary of any loss adjusters (the adjuster's salary is not to be included in
salaries).


Schedule L - Net Commission Expense (page 20):


Any commission your company received on ceded premiums should be listed at item 3 (ceding reinsurance
commission). Item 5 includes only the commission incurred on policy and membership fees, not the fees themselves.
This schedule is no longer optional.
Schedule M - Income Taxes incurred (page 20):


This schedule is used to calculated the income taxes (both state and federal) incurred by the company during
the year.


Schedule N - Other Underwriting Expenses (page 21):


This schedule is used to calculated the amount of expenses (other than commissions) that the company incurred
during the year. Footnotes (a), (b) and (c) on this schedule indicate where the entries in the columns are derived.


Wind Schedule (page 24):


Companies that write a combined policy with another company must not include those wind or liability premiums with
their own premiums on page 1, line 2 of the statement. This would also apply to wind companies that collect fire
premiums on behalf of other companies under a combined policy.


The collection of any wind or liability premiums by your company under such a combined policy must be shown on
page 24, item 2 and as itemized receipts from other sources on page 1. Any commissions or service fees retained or
received by your company must be separately itemized. Remittances to the wind company or others (including both
returns to policyholders and commissions shared with or paid to agents or others) must be shown both on page 24,
item 4 and as separately itemized disbursements on page 2. Commissions relating to combined policies must never
be included with commissions due to directly written business on page 2, line 11.


Any amounts yet to be forwarded to others, including amounts held by your company in separate accounts, must be
shown both on page 24, item 5 and as separately itemized liabilities on page 4.


The fact that your company maintains the wind and/or liability premiums in a separate account, and may in fact name
that account a "premium fund trust account, " does not exclude you from the above reporting requirements. A true
"premium fund trust account," would be established by any agent or agency in their capacity as agent for the wind
and/or liability insurer. The name of your company would not appear on such an account. Neither would your
company place any funds into such an account or withdraw any funds from it.


General Interrogatories (page 25):


The answer to question 21 should specifically identify each class of property insured by your company, such as:
farm property, growing crops, buildings and personal property, residence, or churches, schools and community
buildings.

				
DOCUMENT INFO
Description: Illinois Insurance Company document sample